1. IF:Cardiovascular © 2009 - 2014 PGXL Laboratories

2. Anti-Platelet Therapy Problems and Implications >1 million coronary and peripheral stents placed each year - Clopidogrel is one of the most frequently prescribed drugs; $6B annually 36% of the population has a CYP2C19 variant resulting in consensus- backed recommendation to avoid clopidogrel as ineffective - 2.4x greater risk of cardiovascular event 28% of the population has a CYP2C19 variant resulting in consensus- backed recommendation to avoid clopidogrel due to risk of bleeding Clopidogrel has a pharmacogenetic recommendation in its label

3. Antiplatelet Activation Therapy : Clopidogrel Clinical FactEconomic ImplicationReference 30% of patients are resistant to clopidogrel $19,330 per bleeding event. $40,790 non-fatal MI, $27,314 non-fatal stroke 1,2 PGx guided antiplatelet activation yielded 1% to 4% reduced absolute risk of CV death, MI and stroke. 1% to 4.3% reduced absolute risk of stent thrombosis 3,2 PGx guided therapy in 2C19 IM’s and PM’s verses clopidogrel for all and prasugrel for all. 93% probability of greater net benefit verses clopidogrel for all. $19,330 per bleeding event. $40,790 non-fatal MI, $27,314 non-fatal stroke. Cost of additional Quality Adjusted Life Years was $5K (typical benchmark is $50K for each additional QALY) 4,2 1.Working group on High-On Treatment of Platelet Reactivity. JACC 2010;56:919-933 2.Cost Effectiveness of PGx guided therapy in patients undergoing PCI. Pharmacotherapy 2012;32(4):332-332. 3.Reduced function CYP2C19 genotype and risk of adverse clinical outcomes among patients treated with clopidogrel predominantly for PCI: a meta-analysis. Journal of the American Medical Association. 2010;304:1821-1830 4.Risk-benefit assessment of prasugrel, clopidogrel, and genotype-guided therapy in patients undergoing percutaneous coronary intervention. Clin Pharmacol Ther. 2012 May;91(5):829-837 Property of PGxl Laboratories

4. Pharmacogenetics in Anti- Platelet Therapy Leading Drugs are Metabolized by Genes in the CYP450 Superfamily Cytochrome P450 Enzymes - Enzymes bound to membranes within a cell (cyto) - Contain a heme pigment (chrome and P) - Heme pigment absorbs light at a wavelength of 450 nm More than 50 enzymes in CYP450 - CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5 - 90% of drugs are metabolized by these 6 enzymes

5. CYP2C19 - Clopidogrel Clopidogrel (Plavix) is a PRODRUG ~ 30% of patients have deficiency in CYP2C19 – Decreased amount of active metabolite – High on-treatment platelet reactivity Clopidogrel Property of PGxl Laboratories

6. Influence of CYP2C19 on Clopidogrel Response

7. Scott et al 2013 CPIC Guideline update for 2C19 – clopidogrel. PGx Guideline for Clopidogrel Property of PGxl Laboratories

8. Anti-Platelet Activation Report PGXL Tests and Reports on Kinetics and Dynamics CYP2C19 Poor Metabolizer (PM): This patient’s genotype is consistent with significantly reduced CYP2C19 enzymatic activity. PMs are at increased risk of drug-induced side effects due to diminished drug elimination of active drugs. Patients with no CYP2C19 function (PMs) taking clopidogrel lack adequate antiplatelet response and remain at risk for cardiovascular events, including thrombosis, myocardial infarction, stroke, and death., Ticagrelor

9. Clopidogrel Therapy Who to Test? New patients with ACS having undergone PCI and considered for an antiplatelet prescription: Clopidogrel, prasugrel, ticagrelor Existing ACS patients scheduled for PCI and considered for antiplatelet therapy Existing ACS + PCI patients taking antiplatelet therapy, not previously tested

10. Biochemical and Physiological Effects of Drugs Pharmacokinetics and Pharmacodynamics Pharmacokinetics What the body does to the drug Metabolism, bioavailability Pro-drugs and active drugs Washing the active agent from the body Pharmacodynamics What the drug does to the body Therapeutic, sub-therapeutic, toxic Distribution

11. Incidence of Variants Are Variants Rare or Common? GeneEMIMPMUMTotal CYP2D653%35%10%2%47% CYP2C1936%32%4%28%64% CYP2C957%40%3%NA43% CYP3A487%12%1%NA13% CYP3A51%18%81%NA99%

12. Phenotypes Categories of People With Specific CYP450 Variants (polymorphism) Effective Metabolizer (EM): Normal Genetics Two good copies of the genetic code required for metabolism Intermediate Metabolizer (IM): Reduced enzymatic activity One good copy and one bad copy of code required for metabolism May render the drug a No-Go or require a dose adjustment

13. Phenotypes Categories of People With Specific CYP450 Variants (polymorphism) Poor Metabolizer (PM): Complete lack of enzymatic activity Two bad copies of the code required for metabolism Usually renders a drug a No-Go Ultra Rapid Metabolizer (UM): Higher-than-average enzymatic activity Two bad copies causing much higher than normal metabolism May render the drug a No-Go or require a dose adjustment

14. Pharmacogenetics in Cardiovascular Only Relevant if The Drug is Metabolized by CYP450

15. Pharmacogenetics in Cardiovascular Only Relevant if The Drug is Metabolized by CYP450

16. Consensus Recommendations Our Report Suggests Specific Action For These Drugs CYP2D6 Intermediate Metabolizer  35% of the population Propafenone Avoid or dose adjustment FlecainideDose Adjustment MetoprololDose Adjustment Poor Metabolizer  10% of the population Propafenone Avoid or dose adjustment FlecainideDose Adjustment MetoprololDose Adjustment Ultra Rapid Metabolizer  3-6 % of the Caucasian population  29% of North African and Ethiopian populations  6% of African American populations PropafenoneAvoid MetoprololDose Adjustment

17. Consensus Recommendations Our Report Suggests Specific Action For These Drugs 2C19 Extensive Metabolizer  45% of the population Clopidogrel Efficacious, consider cost saving switch to generic clopidogrel if taking prasugrel or ticagrelor Intermediate Metabolizer  25% of the population ClopidogrelAvoid Poor Metabolizer  2% of the population ClopidogrelAvoid Ultra Rapid Metabolizer  28% of the population ClopidogrelEfficacious, but caution increased bleed risk

18. Consensus Recommendations Our Report Suggests Specific Action For These Drugs CYP2C9 Intermediate Metabolizer  40% of the population WarfarinDose Adjustment Poor Metabolizer  3% of the population WarfarinDose Adjustment VKORC1 High Sensitivity A, AWarfarinDose Adjustment Low Sensitivity G, GWarfarinDose Adjustment CYP3A4 *22 Decreased Metabolizer SimvastatinDose Adjustment AtorvastatinDose Adjustment LovastatinDose Adjustment SLCO1B1 2.6-fold Increased myopathy risk SimvastatinDose Adjustment AtorvastatinDose Adjustment >5-fold increased myopathy risk SimvastatinAvoid AtorvastatinDose Adjustment

19. Anti-Coagulation Problems and Implications 25 million warfarin prescriptions (2010) Warfarin has a narrow therapeutic window and a wide range of patient responses -Patients who are seemingly similar can require 10-20 fold difference in dosage Anti-Coagulation agents consistently rank at the top of the mist of most dangerous prescribed medications -179,855 serious or fatal drug reactions (2011) 20% of those hospitalized had bleeding events -Cost to treat: $13,500 per event (2006) -If receive thrombosis: $39,500 per event (2006) -Clopidogrel is one of the most frequently prescribed drugs; $6B annually Continued…

20. Anti-Coagulation Problems and Implications Pharmacogenetic guidance lowered bleeding events by 43% -Reduced hospitalization for all causes 33% Warfarin has a pharmacogenetics warning in the label …Continued

21. Warfarin Therapy Who to Test? New warfarin patients initiating therapy – These patients are at the highest risk of serious adverse events during the first month of taking warfarin. Patients already taking warfarin and having difficulties stabilizing within the therapeutic INR range for reasons that are unexplained by environmental factors. These patients may be more easily managed if their phenotype is known. Patients already taking warfarin who are scheduled for a surgical procedure.

22. Pharmacogenetics in Cardiovascular In Addition to CYP450, PGXL Also Tests for VKORC1 Cytochrome P450 Enzymes - Enzymes bound to membranes within a cell (cyto) - Contain a heme pigment (chrome and P) - Heme pigment absorbes light at a wavelength of 450 nm More than 50 enzymes in CYP450 - CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5 - 90% of drugs are metabolized by these 6 enzymes VKORC1 predicts warfarin sensitivity

23. Phenotypes Categories of People With Specific CYP450 Variants (polymorphism) Effective Metabolizer (EM) - Normal genetics - Two good copies of the genetic code required for metabolism Intermediate Metabolizer (IM) - Reduced enzymatic activity - One good copy, one bad copy of code required for metabolism - May render the drug a no-go or require dose adjustment Poor Metabolizer (PM) - Complete lack of enzymatic activity - Two bad copies of required code - May render the drug a no-go or require dose adjustment

24. Incidence of Variants Are Variants Rare or Common? GeneEMIMPMUMTotal CYP2D653%35%10%2%47% CYP2C1936%32%4%28%64% CYP2C957%40%3%NA43% CYP3A487%12%1%NA13% CYP3A51%18%81%NA99% VKORC1 Caucasians African Americans Asians High Sensitivity 13%2%81% Intermediate Sensitivity 47%24%18% Low Sensitivity 40%74%1%

25. Pharmacogenetics of Warfarin Only Relevant If the Drug is Metabolized by CYP450

26. Cardiovascular Activation Report PG XL Tests and Reports on Kinetics and Dynamics CYP2C9 Poor Metabolizer (PM): This patient’s genotype is consistent with significantly reduced CYP2C9 enzymatic activity. Reduced CYP2C9 activity leads to lower dose requirement (e.g., warfarin) due to decreased clearance, increased elimination half-life, and increased time to reach steady-state blood concentrations. VKORC1 Intermediate Warfarin Sensitivity: ‡The warfarin maintenance dose estimate was derived using a published formula that accounts for age, gender, weight, and CYP2C9 and VKORC1 genotypes. This estimate should be viewed as an example of how this information can be taken into consideration by the physician as part of the overall patient management strategy.

27. Incorporating PGX: Considerations for whom to test? CV Candidate for AP, AC, Statin Rx ACS-PCI, new warfarin initiation Unstable INR Bleeding, thrombotic event, myopathy Effient, Brilinta, Pradaxa, Xarelto Rx Pain Patient Pain Candidate for Opioid Rx Opioid ADR or sub-optimal response Opioid abnormal UDT Side effects to NSAIDs, muscle relaxers, triptans Behavioral Candidate for Psychotropic Rx Psychotropic ADR or sub- optimal response More than 1 psychotropic Rx Treatment resistant, uncontrolled, hosp admission in past 6 months Polypharmacy, Clinical Hx ADRs, Pre-therapeutic screening for all patients Property of PGxl Laboratories

28. Polypharmacy Diabetes Hyperlipidemia Coronary Artery Disease Hypertension Thrombosis Stroke Depression Psychosis ADHD Arrhythmia Chronic Pain CIPHER manages the whole patient Property of PGxl Laboratories